Q: We are planning to open a new clinic that will offer both primary care and urgent care services. Can we use the same tax identification number (TIN) when we start negotiating contracts with insurance payors?
A: Based on our experience with doing this many times, if you attempt to use the same TIN for both primary care (PC) and urgent care (UC), you are likely to see the following results:
- Some payors are likely to refuse to give both contracts to the same entity.
- Some will be fine with giving both contracts to the same entity, but their processing software will cause major problems with payments. We have seen the payors not pay on the UC patients for months, causing serious cash flow issues. In general, the payor does not upgrade their processing software, and the only solution is two different TINs.
- Some will be fine with giving both contracts to the same entity, but may—unbeknownst to their own contracting specialist—end up processing all claims (UC and PC) at the lowest rate for each line item or each overall claim. Again, in general, the payor does not upgrade their processing software, and the only solution is two different TINs
- Some payors may offer two contracts to the same TIN and may be able to process accurately claims with POS -11 for office (PC) and POS -20 for urgent care.
Although the last option may happen for a few payors, it is almost certainly not going to work for the majority. Thus, our recommendation is to contract for one TIN for UC and another TIN for PC.
Q: Can you offer guidance on how to use the new codes regarding the completion of health risk assessments?
A: Effective January 1, 2017, the American Medical Association (AMA) deleted Evaluation and Management code (E/M) code 99420, “Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal)” and introduced Current Procedural Terminology (CPT) codes 96160, “Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument” and 96161, “Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument.” These codes were added in the Medicine section to allow alignment with other assessments. They are intended to identify practice expense only, as they are for the administration of the health risk assessment instrument typically given by non-physician clinical staff.
According to the AMA, adding the term “patient-focused” to the descriptor of new code 96160 and “caregiver-focused” to code 96161 clarifies the intents of each code, which was lacking before. For identification of additional components inherently included as part of the services, the phrase, “…with scoring and documentation, per standardized instrument” was added to the descriptor for both codes.
For example, a teenaged patient presents to the urgent care with a possible concussion after being tackled during a football game. An Acute Concussion Evaluation (ACE) form is completed by clinical staff. Code 96160 can be billed for scoring of the standardized instrument for the patient.
The AMA offers the following clinical example for billing code 96161: “An intellectually disabled patient is accompanied by his parent/caregiver during a preventive medicine service visits. The parent/caregiver admits the patient is increasingly more difficult to manage and things are falling apart at home. The depression inventory is selected and prepared for completion by the clinical staff, who explained the purpose and how to complete the instrument to the patient’s parent/caregiver. Upon completion of the instrument by the parent/caregiver, the clinical staff scored the instrument and recorded the results. The clinical staff provided summarizing feedback to the parent/caregiver regarding instrument scoring and provided the physician or other qualified healthcare professional with the results of the depression inventory.”
Services provided by the physician are captured in the E/M code reported for the patient encounter. This includes interpretation of the rating scale, discussion of the results, summary report in the patient’s medical record, and any referral to the parent’s/caregiver’s personal primary care provider or mental health provider.
Keep in mind these codes are not to be used with codes 99408, “Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes” and 99409, “Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minutes.”